Dysphagia in Children

Dysphagia is a term that means “difficulty swallowing.” This condition is the inability of food or liquids to pass easily from your child’s mouth, into their throat, and through the esophagus to the stomach during the process of swallowing.

Swallowing involves three stages, which are controlled by muscle and nerves that connect your child’s oral cavity, upper airway, and digestive tract to their brain.

1. Oral preparation stage: This is the first stage where food and liquid is chewed and moistened by saliva in the mouth. The tongue pushes food and liquids to the back of the mouth toward the throat. (This phase is voluntary, meaning we have control over chewing and beginning to swallow.)
2. Pharyngeal stage: Food enters the pharynx (throat). A flap called the epiglottis closes off the passage to the larynx (voice box) and the vocal cords close so food does not get into the lungs. The muscles in the throat relax, and food and liquid are quickly passed down the pharynx (throat) into the esophagus. The epiglottis and vocal cords open again so we can breathe. (This phase starts under voluntary control, but then becomes an involuntary phase that we cannot consciously control.)
3. Esophageal stage: Food passes through the esophagus into the stomach by gravity. Muscles in the esophagus push food toward the stomach in wave-like movements, known as peristalsis. A muscular band between the end of the esophagus and the upper portion of the esophagus (known as the lower esophageal sphincter) relaxes in response to swallowing, allowing food and liquids to enter the stomach. (The events in this phase are involuntary.)

Swallowing disorders like dysphagia occur when one or more of these stages fail to take place properly. Health problems that can affect swallowing in children include:

• Eosinophilic esophagitis
• Achalasia
• Connective tissue disorders
• Gastroesophageal reflux disease (GERD)
• Prematurity
• Developmental delays
• Laryngeal cleft
• Vocal cord paralysis
• Cleft lip and palate or other craniofacial anomalies
• Large tongue or tonsils
• Diseases that affect the nerves and muscles, such as:
  • Stroke
  • Tumor
  • Nerve injury
  • Brain injury
  • Muscular dystrophy, and can cause paralysis or poor function of the tongue or the muscles in the throat and esophagus
• Prenatal malformations of the digestive tract, such as esophageal atresia or tracheoesophageal fistula
• Irritation from being on a ventilator for a prolonged period of time
• Having a tracheostomy (artificial opening in the throat for breathing)
• Compression of the esophagus by other body parts, such as the heart, thyroid gland, blood vessels, or lymph nodes
• Foreign bodies in the esophagus, such as a swallowed coin

If your child is suspected to have dysphagia, their physician will obtain their medical history and examine your child. You will be asked questions about how your child eats and any problems you notice during feeding. Imaging tests may also be ordered to evaluate your child’s mouth, throat, and esophagus. These tests can include:

• Videofluoroscopic swallow study (also called a modified barium swallow study). Your child is given small amounts of a liquid that contains barium (a chalky liquid used to coat the inside of organs so that they will show up on an X-ray) to drink with a bottle, spoon, or cup, or spoon-fed a solid food containing barium. They are seated upright or in the position that you feed them in at home. A series of moving picture X-rays are taken to evaluate what happens as your child swallows the liquid.
• Barium swallow/upper GI series. Your child is given a liquid containing barium to drink and a series of X-rays are taken. They will be lying down on their back for this test. The physician can watch what happens as your child swallows the fluid, and note any problems that may occur in the throat, esophagus, or stomach.
• Endoscopy. This test uses a small, rigid, or flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of part of your child’s airway and digestive tract. An endoscopy is performed under anesthesia. Pictures are taken of the inside of the throat, airway, esophagus, and the stomach to look for abnormalities. Small tissue samples, called biopsies, can also be taken to look for problems.
• Esophageal manometry. In this procedure a small flexible tube is placed into the nose and passed into the esophagus. It can determine how well your child’s esophagus is working by measuring the pressure and coordination of the esophageal muscles.
• Flexible laryngoscopy is an examination done in the office to assess the upper airway and status of vocal cord, which are essential part of evaluation of children with swallowing discoordination.
• Fiberoptic endoscopic evaluation of swallowing (FEES). In this test, a flexible camera is passed through your child’s nose and is used to see parts of the throat as they swallow to assess the status of swallowing and any indication for aspiration.

When treating dysphagia in children, feeding therapy can be helpful. Therapists can educate and work with families to help make swallowing more effective, or suggest techniques or modifications to your child’s diet that may help improve swallowing problems. However, it is critical to be sure there are no anatomical issues in the oral cavity, upper airway, esophagus, and stomach that may require surgical intervention.

Infants and children with dysphagia are often able to swallow thick fluids and soft foods (such as baby foods or pureed or blended foods) easier than thin liquids. A speech-language pathologist may recommend that you thicken your child’s liquids and will work with you to create the correct recipe. They may also change the type of cup or bottle your child is drinking from that can help slow the flow of liquids. Some infants who had trouble swallowing formula will do better when they are old enough to eat baby foods from a spoon. Your child’s speech-language pathologist may be able to recommend other commercial products that help thicken liquids and make them easier to swallow. The use of thickeners has to be approved by your child’s doctor.

If your child also has symptoms of reflux along with dysphagia, treating this condition may produce improvements in your child’s ability to swallow. As the esophagus and throat are less irritated by acid reflux, their function may improve. Treatment of dysphagia include:

• Remaining upright for at least an hour after eating
• Thickening your child’s liquid
• Medications to decrease stomach acid production
• Medications to treat inflammation
• Medications to help food move through the digestive tract faster
• Surgery of the upper airway and larynx to repair anatomical issues
• Surgery to help repair the esophagus or stomach

Our skilled clinicians in the Aerodigestive Center, Center for Airway Disorders, Motility and Functional Gastrointestinal Disorders Center, and Feeding and Swallowing Program at Boston Children’s Hospital are experienced in diagnosing and treating children with dysphagia.

Your child may also receive care through our Speech-Language Pathology Program affiliated with these centers. Boston Children’s Hospital also offers a unique Feeding and Swallowing Program, which diagnoses and treats infants, toddlers, and school-aged children with a variety of feeding and swallowing problems. Our interdisciplinary staff includes:

• Gastroenterologists
• Pulmonary specialists
• Otolaryngologists
• Speech and language pathologists
• Radiologists

Our team thoroughly evaluates your child’s oral motor skills, swallowing and feeding skills, and nutritional intake.